The proposed RE-INSPIRE (Rich-context Evaluation of INSPIRE) Service-Directed Project (SDP) will investigate how and why local quality improvement initiatives within VA differ so widely in terms of success, spread, and sustainability by conducting a rigorous evaluation of the impact of context. RE-INSPIRE will embed a prospective, longitudinal, and mixed-methods study of context in an existing randomized-controlled trial of stroke care improvement at 14 VA sites across the United States. It will constitute a major collaboration between the VA Stroke Quality Enhancement Research Initiative (QUERI) and VA-CASE, one of four Veterans Engineering Resource Centers (VERCs) in the United States. As part of this QUERI-VERC partnership, RE-INSPIRE investigators will include nationally-recognized VA experts in implementation science and engineering. The study in which RE-INSPIRE will be embedded is the recently-funded Intervention for Stroke Performance Improvement Using Redesign Engineering (INSPIRE) SDP. Using an experimental design with random assignment, INSPIRE evaluates the effect of a Systems Redesign-based Collaborative plus monthly quality performance reporting on improving VA inpatient acute ischemic stroke care, as compared to the effect of quarterly performance feedback alone. RE-INSPIRE will enhance and extend the original INSPIRE evaluation (1) with an in-depth study of context and (2) continuing site visits and data collection at the 14 participating VA facilities more than a full year after the end of INSPIRE in order to assess in detail issues of spread and sustainability. The specific aims of the three- year RE-INSPIRE study include: (a) evaluating the impact of context on implementation mechanisms used at 7 sites randomly assigned to participate in a Systems Redesign-based intervention (including a Collaborative); (b) evaluating the impact of context on effective and ineffective local initiatives to improve acute stroke care across 14 intervention and control sites participating in the INSPIRE randomized-controlled trial; (c) evaluating the impact of context on the spread and sustainability of local initiatives to improve acute stroke care across the 14 INSPIRE intervention and control sites. The Consolidated Framework for Implementation Research will serve as the study's conceptual framework. RE-INSPIRE investigators will collect context-related data through annual site visits at all 14 VA facilities; conducting semi-structured interviews (annually in person and quarterly by phone), administering nine standardized measures (including the Team Development Measure); and performing ongoing document/artifact capture. Data analysis will include the pilot administration of a new data integration strategy in which multiple types of data from multiple sources and sites will be imported into a single cumulative project file using advanced software. The data in this unified project file will then be systematically explored, queried, and analyzed, culminating in the ability of RE-INSPIRE investigators at study's end to explain with evidence the impact of context on implementation mechanisms, on the effectiveness of local quality improvement initiatives, and on spread and sustainability. The proposed RE-INSPIRE project includes a plan to disseminate this context matrix approach to VA researchers, leaders and planners who see potential value in a new, evidence-based method to track improvement and progress across a wide variety of multi-site initiatives within the VA. PUBLIC HEALTH RELEVANCE: As part of its fundamental commitment to provide high-quality healthcare to veterans, the VA supports quality-improvement initiatives at VA medical centers and facilities across the country. In these initiatives, local VA teams work together to improve quality of care by developing new, improved ways to meet veterans' needs. The members of these local improvement teams often come from different services and departments within the VA. The solutions these teams develop and implement are frequently innovative because they represent the best thinking of a diverse group of individuals who work as a team to improve healthcare for veterans at their facility. The proposed RE-INSPIRE study helps the VA support these local quality improvement efforts. By identifying how different factors related to local context help or hinder initiatives to improve stroke care at 14 VA facilities, the RE-INSPIRE study will discover what people involved in local quality improvement efforts most need in order to succeed in their efforts to enhance quality of care for veterans.